Lecture 2.3 Hair, Skin, Nails (5%)

Question 1

What are the two types of hair? Describe each

Answer 1

1) Vellus: short, fine and unpigmented
2) Terminal: coarse, thick and conspicuous (usually pigmented

Question 2

1) What do sebaceous glands do?
2) What are the 2 categories of sweat glands? Describe each

Answer 2

1) Sebaceous glands produce oils
2)
-Eccrine: widely distributed; open to skin
-Apocrine: in axillary and genital regions

Question 3

List 3 important red flags for skin

Answer 3

Pallor, cyanosis, and jaundice

Question 4

1) What does pallor indicate?
2) Why?

Answer 4

1) Anemia
2) Hemoglobin in RBC’s transports oxygen and gives a red color to oxygenated blood and skin

Question 5

1) What does cyanosis indicate?
2) Why?

Answer 5

1) Low oxygen or decreased blood flow
2) Deoxyhemoglobin has a bluer tint; seen in veins
-Veins also given bluish color due to light shift as it passes through pella lucidum

Question 6

1) What does jaundice indicate?
2) What is this?

Answer 6

1) Jaundice indicates buildup of bilirubin (yellow)
2) Biproduct of the breakdown of heme in RBC’s

Question 7

What are 3 more integumentary system red flags?

Answer 7

1) Growths
2) Rashes
3) Hair loss or nail changes

Question 8

What should you ask regarding growths?

Answer 8

1) “Have you noticed any changes in your skin, hair, nails?
2) “Have you had any rashes, sores, lumps, itching?”
-If they report a new growth, make sure to pursue entire history of illness
3) Also include personal and family history of skin cancer.
-“Anyone in your family had a cancer removed?”
4) Note type, location, date of any past skin cancers
5) Ask about self-skin examinations
6) Ask about sunscreen use

Question 9

What should you ask about rashes?

Answer 9

1) Ask about itching. Most common symptom with ratches
-Did the itching come before or after the rash started?
3) Ask about seasonal allergies: sneezing, watery eyes
4) Ask about asthma
5) Does itching get worse at night?
6) WHERE IS THE RASH?
-Location will give you many clues to the cause; you will learn specifics later
7) HOW LONG HAS IT BEEN THERE?

Question 10

What is the most common symptom with rashes?

Answer 10

Itching

Question 11

What can generalized itching without apparent rash indicate?

Answer 11

Includes:
1) Xerodermata (dry skin)
2) Pregnancy
3) Uremia
4) Jaundice
5) Lymphoma and leukemia
6) Drug reaction
7) Polycythemia vera

Question 12

What 4 things should you ask about hair loss or nail changes? What could these answers lead you to conclude?

Answer 12

1) Ask about where the loss is
2) Ask about the timing
3) Learn where the hair breaks
4) Ask about care practices like shampooing and special products
-Shedding at the roots includes telogen effluvium and alopecia areata
-Breaking at the shaft suggests tinea capitis
-Change in hair or nails (thickening or thinning) can also be due to thyroid disease

Question 13

1) What does hair breaking at the shaft suggest?
2) What can changes in hair or nails (thickening or thinning) be due to?

Answer 13

1) Tinea capitis
2) Thyroid disease

Question 14

1) What are causes of hair loss?
2) What two things could hair shedding at the roots indicate?

Answer 14

1) MC causes are pattern baldness
2) Telogen effluvium and alopecia areata

Question 15

1) How many Americans does skin cancer affect?
2) What are the risk factors?
3) Who’s at the highest risk?

Answer 15

1) One in five Americans
2) Combined genetic predisposition and UV radiation
3) Fair-skinned individuals

Question 16

What are the types of skin cancer in order of commonality? (from most to least)

Answer 16

Basal > squamous > melanoma

Question 17

1) Is the metastasis rate of melanoma high? What about mortality
2) Is it rare or common? What percent of skin cancer deaths does this type make up?
3) Is it treatable?

Answer 17

1) Yes, has a high metastasis rate and high mortality
2) Rarest form of skin cancer, but accounts for 70% of the deaths
3) If you catch it early it is very treatable

Question 18

List 10 risk factors for melanoma

Answer 18

1) Family history of melanoma
2) >/= 50 moles
3) Atypical or large moles, especially if dysplastic
4) Red or light hair, light eye or skin color
5) Solar lentigines (brown macules on sun-exposed areas)
6) Freckles
7) UV radiation from heavy sun exposure, sunlamps, tanning booths
8) Severe blistering sunburns in childhood
9) Immunosuppression (HIV or chemo)
10) Personal Hx of nonmelanoma skin cancer

Question 19

List 6 signs of skin damage

Answer 19

1) Numerous solar lentigines on shoulders and upper back
2) Many melanocytic nevi
3) Solar elastosis: yellow thickened skin with bumps
wrinkles or furrowing
4) Cutis rhomboidalis nuchae: leathery thickened skin on the posterior neck
5) Actinic purpura

Question 20

What are the two best ways to prevent skin cancer?

Answer 20

1) Avoid UV radiation and Tanning Beds
2) Use sunscreen
-It’s not complicated; sunscreen works
-Use SPF >/= 30

Question 21

How does timing affect skin cancer prognosis?

Answer 21

1) Remember if caught early the prognosis drastically improves
2) Pt’s that received skin exam within 3 years of developing melanoma generally have less advanced disease

Question 22

1) What should you educate your pts about regarding skin cancer?
2) How often does melanoma evolve de novo (not from an existing mole)?

Answer 22

1) Educate about self-exam, make sure you and your patient know the ABCs, and remain vigilant as PCP’s
2) ½ of melanoma evolves de novo

Question 23

List the ABCs of melanoma

Answer 23

Asymmetry
Border irregularity
Color variation
Diameter greater than 6mm
Evolving (changing over time)

Question 24

What is the most important ABC of melanoma?

Answer 24

Evolution (changing over time)

Question 25

What are the two types of flat lesions? How are they differentiated?

Answer 25

1) Macule: flat and < 1cm
2) Patch: flat and >1cm

Question 26

What are the two types of raised lesions? How are they differentiated?

Answer 26

1) Papule: raised and < 1 cm
2) Plaque: raised and > 1cm

Question 27

What are the two types of fluid filled lesions? How are they differentiated?

Answer 27

1) Vesicles: raised and fluid filled < 1 cm
2) Bulla: raised and fluid filled > 1 cm

Question 28

What types of lesions can be palpated? What kind can’t?

Answer 28

Raised lesions can be palpated, flat lesions cannot be palpated with eyes closed

Question 29

What are two things you need to note about fluid filled lesions?

Answer 29

1) Number
2) Size (good to measure)

Question 30

What should you do for all skin lesions? (2 things)

Answer 30

1) Inspect and palpate all skin lesions
2) Ascertain their relatability to any descriptive words you know

Question 31

1) What should you note about a rash?
2) What descriptive words should you use for this?

Answer 31

1) Shape of the rash
2) Circular, oval, annular (ring-like with central clearing), nummular (coin like, no central clearing)

Question 32

What should you note about a rash’s color

Answer 32

Whether or not it’s skin colored (same color as pts skin)

Question 33

What words should you use to describe a rash’s texture?

Answer 33

Smooth, fleshy, verrucous or warty, scaly, sandpaper-ish, rough, etc

Question 34

What things should you describe about a rash?

Answer 34

(First, inspect and palpate)
1) Shape
2) Color
3) Texture
4) Location
5) Configuration
6) Blanching or non-blanching?

Question 35

1) What should you note about a rash’s configuration?
2) What can this suggest or rule out?

Answer 35

1) Is it a part of a pattern?
2)
-Herpes zoster is dermatomal
-Herpes simplex occurs in grouped vesicles or pustules
-Pustule is a small, palpable collection of neutrophils or keratin that appears white

Question 36

1) Blanching lesions can be described as what?
2) What does blanching suggest?
3) What do non-blanching rashes include?
4) What does a rash not blanching indicate?

Answer 36

1) Blanching lesions are erythematous
2) Blanching suggests inflammation
3) Non-blanching include petechiae purpura
4) Vasculature structures are affected

Question 37

What should you always check regarding a rash?

Answer 37

Always see if the rash you are investigating blanches

Question 38

What is the sequence of a physical exam for the integumentary system? (5 steps)

Answer 38

1) Start with scalp, making sure to part the hair
2) Inspect head and neck: including forehead, eyelashes and eyebrows: nose, cheeks, lips, oral cavity and chin – and anterior neck
3) Inspect shoulders arms and hands
4) Inspect chest and abdomen
5) Inspect thighs and lower legs

Question 39

1) What should you check regarding the scalp?
2) What may focal patches suggest?
3) What is sparse hair seen in? What about fine and silky hair?

Answer 39

1) Part the hair and check for hair loss, which can be diffuse, patchy or total
2) Alopecia areata
3) Sparse hair is seen in hypothyroidism, fine and silky hair in hyperthyroidism

Question 40

What is the first part of a skin exam?

Answer 40

Start with scalp, making sure to part the hair

Question 41

1) What body parts of the head and neck should you look at when conducting an integumentary system exam?
2) What should you look for? Where in particular should you pay close attention?

Answer 41

1) Forehead, eyelashes and eyebrows, nose, cheeks, lips, oral cavity and chin, and anterior neck
2) Basal and squamous carcinomas, esp on bridge of nose and ridge of auricles

Question 42

1) What should you look for regarding shoulders, arms, and hands?
2) What should you do when inspecting the chest and abdomen?
3) What should you do when inspecting thighs and lower legs?

Answer 42

1) Look for color change, shape, lesions
2) Lower gown where needed
3) Expose skin between toenails and always check soles and palms

Question 43

What are the 6 key things to visualize regarding the integumentary system? Where should you look for each?

Answer 43

1) Assess the scalp
2) Assess for erythema/rash: Upper lower extremities and trunk + additional visible skin
3) Assess pallor: Occurs in lips/oral mucosa, lips, palms/soles
4) Assess cyanosis: Occurs in lips, oral mucosa, nails, palms/soles
5) Assess jaundice: Occurs in sclera, conjunctiva, lips, oral mucosa, any visible skin
6) Assess hypo/hyper pigmentation: Upper and lower extremities and trunk + additional visible skin

Question 44

What should you palpate about the skin/ hair/ nails? (6 things)

Answer 44

1) Temperature: felt with fingertips
2) Turgor: checked in two places
3) Hair: distribution assessed over scalp, face, and remaining body
4) Nails: assessed for shape, pitting, color
5) Lesions: palpate and assess quality (papule, macule, etc)
6) Moles: palpate and assess border, color, etc.
* Add patient counseling on ABC’s